Exclusive ECF Interview: Dr Konstantinos Farsalinos

“If you’re expressing your opinion about e-cigarettes in public, you should know what you’re talking about…”

Dr Konstantinos Farsalinos is a Greek cardiovascular specialist who in recent years has become increasingly high-profile internationally on account of his groundbreaking clinical research into e-cigarettes and the effects of their use.

He spoke to ECF as he embarked on a study into the ingredients of e-liquids that was made possible through crowdfunding by vapers and e-cigarette companies.

We talked to him about his work, the future of vaping and how not all the reputed experts are telling the truth.

E-Cigarette Forum: Your day job is in cardiovascular research at a Belgian hospital, so what led you from that to focus on e-cigarette research? Some might struggle to see the link.

Dr Farsalinos: It came up by coincidence. I’d just finished a study detecting cardiac dysfunction in smokers, when two friends sent me a picture message showing them with their new e-cigarettes.

My first reaction was that they’d wasted their money on a gimmick; if they really wanted to quit smoking I’d prescribe them with medication. But they stuck with it and continued sending me pictures of them vaping. After a while I saw that it really was working for them.

It struck me that this was something that needed to be looked at properly, at a scientific level, so I set out to conduct some research into the potential benefits. I discovered a Greek e-cigarette forum and that’s where I found the volunteers for my first clinical study into e-cigarettes.

A large number of people in the medical field seem to have taken an automatic stance against e-cigarettes. Does it feel like you and your team are treading a lonely path?

Last year, I felt quite lonely. There were just a handful of us conducting e-cigarette research and we were probably considered crazy by most of the others in our field. But we are growing; e-cigarettes get more backing every day. In the last few months we’ve had more and more people from the scientific and medical fields support us

Why are those people coming around now?

There’s still not enough data from research yet, but there is far more than what was available in previous years. During that time the public has really taken to e-cigarettes too, despite the negative publicity. I think these factors have convinced people to look closer.

I believe most of the people expressing negative opinion about e-cigarettes don’t really have any deep knowledge about the products. If you’re expressing your opinion about e-cigarettes in public you should know what you’re talking about, because the things we say as scientists influence a lot of people.

I know a lot of smokers who were put off right at the point of trying an e-cigarette. Even worse, I’ve seen a lot of vapers go back to smoking after hearing scientists discuss the potential hazards of e-cigarettes – the problem is that they often forget to mention the dangers of smoking.

There’s a depressing irony at play there.

Nobody is expecting e-cigarettes to be an absolutely safe and healthy habit though…but they don’t have to be.

That’s interesting, because from what I see in the press some people won’t be happy with vaping unless it’s 100% risk-free.

Do you know any medication that has no side effects? For example: Paracetamol is used the world over, but it’s the number one cause behind people ending their own lives. If you take just 10 tablets at once, you can develop acute liver necrosis.

It’s important to be clear that we’re not saying e-cigarettes are a good thing overall. They’re a good thing for a smoker, they’re not a good thing for everyone else.

I wouldn’t suggest non-smokers take up vaping. But for smokers, considering the devastating effects of tobacco, there is no comparison. It’s a complete revolution in tobacco harm reduction. Although the ideal thing would be for vaping to be just a bridge to quitting smoking, where at the end you stop vaping too.

The biggest difference between smoking and vaping is that tobacco cigarettes were made to turn non-smokers into smokers. Since the beginning, e-cigarettes have been marketed for smokers to become vapers, not for non-smokers to become vapers.

E-cigarette companies don’t need to target youngsters or non-smokers and that’s the big difference that Tobacco Control refuses to accept.

Yet the press often runs stories about children vaping, or how vaping is considered cool amongst their peers, just like smoking. Is there any truth in that?

We have data from the USA and the UK on this, but the headlines don’t match the results once you look at them properly – the best example being the latest CDC study.

Some very vocal people at the CDC are making out that we are witnessing a new nicotine epidemic from e-cigarettes. But they weren’t asking these young people if they were regular users. The results were based on the question ‘have you tried an e-cigarette in the last 30 days?’ According to the CDC you’re a user if you’ve had even one puff in the last 30 days. Yet if you took the number of young people who were not smokers but had tried an e-cigarette over the last 30 days, the number was just 0.5%. They presented that result as a problem, which it is not. According to common sense, 0.5% is almost non-existent.

Others have exaggerated the results even more. I won’t name anyone simply because I don’t want to give them the oxygen of publicity, but there are professors of medicine in the United States whose statements on this make them look ridiculous. Unfortunately they’re using the official websites of universities to do it, so they’re ridiculing the universities too.

It’s something I just can’t understand, I would never disgrace myself in that way. You only need to check the numbers to see that the public statements they make after these studies are nonsense.

Have any of your own studies been misrepresented?

The EU has certainly been guilty of isolating sentences in my studies and presenting them in a different context.

I can’t blame the regulators for not being scientists or experts in everything they legislate, of course. But at the least they should read the detailed documents and ask for clarification and advice when they need it. Often they don’t do this. They just take a sentence that fits their agenda and use it to apply regulations that affect millions of people.

I wasn’t surprised by the EU regulators’ reaction to e-cigarettes. The problem for them is that they acted too late because there are so many millions of users in Europe that they can’t ignore them.

And that’s why they can’t ban them or apply medicinal regulations. If they’d tried to do it three years ago, no one would have paid attention and there would have been little reaction. But they came too late. That’s good for the e-cigarette and good for smokers.

The current EU regulation has significant problems of course, particularly around nicotine limits. The current limit is very low. I’ve done two studies on nicotine absorption from e-cigarettes, including the only study that used a third generation device at 9w with a clearomizer. Although we used experienced vapers, the levels of absorption were around one third of that from tobacco – you’d need to vape for 35 minutes to get plasma nicotine levels similar to smoking one tobacco cigarette in five minutes.

This shows that e-cigarettes are inefficient at providing nicotine at the same level, especially at the same speed, as tobacco cigarettes.

If they were more efficient, would they be more effective as a smoking cessation device?

Of course, the more you simulate the nicotine delivery from smoking the better it will be. There are a lot of things to be done to improve e-cigarettes. But having an upper limit of 20mg is a big step back.

That’s quite a controversial point to make though, that e-cigarettes should be stronger.

It is, but there are other issues too. The latest studies show that nicotine needs some other chemicals present in tobacco to be really addictive. It’s not as addictive on its own as we thought.

I’m not saying that it’s not addictive at all of course, but it seems that other alkaloids largely potentiate the addictive properties of nicotine. These are not present in e-cigarettes.

I doubt that a non-smoker could be addicted to e-cigarettes. I’m not saying it’s impossible, but I think it’s very difficult.

How much of your life does your work around e-cigarettes take up?

The majority of it. In order to do research you have to be a little bit crazy, and you have to really love research. It’s not just a profession.

But it’s not just about performing the actual research, a lot goes into a study, and a single study is a very difficult thing to do. First of all you have to plan the research and design the protocols around it. Then you have to find the funds. It also needs to be approved by the hospital’s ethics committee. Once those stages are complete you have to find volunteers. So there’s a lot to be done before you even start.

How many vaping studies have you done now?

So far I’ve published seven, with a further three accepted and awaiting publication. I have several more protocols ready on my desk, already approved by the ethics committee, including one to look at detecting metabolites of carcinogenic substances in smokers compared to vapers. They’re just waiting for someone to provide the money to do them. If I had the money I would start tomorrow.

How do you usually fund your studies?

Some of the studies I’ve done that haven’t required expenses, such as hospital or lab fees, were performed for free. One example is the Vaping Topography Study where my team and I worked without being paid during our free time, even during weekends. I can’t even count the number of hours we put in video-recording people vaping and analyzing the results with specialized software.

But even with my team’s willingness to work for free we just can’t undertake expensive clinical studies.

For example when we did the Coronary Flow Velocity Study the hospital where the study was performed asked for €240 per person, per examination. The study involved more than 80 volunteer participants, each of whom required two examinations. That’s a lot of money, and that’s just the hospital fee.

Studies often need a number of people working on them. It’s impossible for me to administer an intravenous injection and perform a cardiogram at the same time. There has to be someone else helping me, usually more than one.

Decades ago smoking was promoted as being healthy, because of research we know now that the complete opposite is true. Do you think that people are scared of admitting vaping could be less dangerous than smoking in case they’re proved wrong at some point in years to come and held responsible?

That’s why my main statements are that e-cigarettes, according to current research, are by far less harmful than tobacco. I’m not saying it’s safe, I’m not saying it’s a healthy habit so that everyone should go ahead and do it. I’m just comparing it with the effects of tobacco, knowing what’s in tobacco smoke.

Of course, there are many things that we need to know on a laboratory level, from the effects of various materials on the release of heavy metals and toxins in the vapor to analyzing the consequences of chemicals released through high-wattage e-cigarette use. There are currently endless possibilities for research, we have many protocols prepared, but funding is missing.

So we have to be cautious with e-cigarettes. For example we have no idea what’s happening when we inhale flavors. Most of those are approved for use in food but have not been tested for inhalation.

That brings us to your current study regarding potentially harmful ingredients in liquids. Can you elaborate on that?

I started doing this study based on one-or-two samples in which we found some chemicals that shouldn’t have been there.

There’s a lot of anxiety around this, which I understand of course, and people ask me about it every day. But we have to define the problem first, which is what my team and I are doing now. If we talk about this without defining the problem we run the risk of creating ‘news’ that isn’t accurate.

We’re testing around 160 liquids from all over the world. We want to see if a problem exists on a global scale, and to what extent. When we have our findings we’ll announce how many liquids were affected and what we found within them. But we’ll also present our proposal for a solution, because just defining the problem means nothing.

What’s the main issue right now as you see it?

There’s currently no widespread testing of products as they’re made, this is a problem. Another problem is the lack of knowledge held by companies that manufacture and sell e-liquid. This industry has developed form small and medium-sized companies; there is no big industry (until recently). They don’t know what to test, even if they want to invest their money on it. So they’re “trapped”.

I’ve seen some companies trying to do testing, but it’s been useless, providing almost zero useful information. They’re searching over the Internet, asking chemical labs what they should do. But most scientists, even those who are very respected experts in their field, lack the required knowledge if they haven’t worked on e-cigarettes specifically. They’re a very complicated new product, we’ve never seen anything of this complexity before – it’s an integration of chemistry, technology, electronics and physics.

It’s so complicated that I’ve seen experienced labs making huge methodological mistakes when we gave them an e-cigarette to test. It’s very important to know what you’re doing, because at a laboratory level it’s extremely easy to misuse them and produce useless unrealistic results. If the tests don’t represent the way the product is used by vapers, then what is the point?

One of the arguments you hear from smaller companies is that they couldn’t afford to test their own products and survive as a business.

Well, in reality only producers need be responsible for testing. Retailers don’t have to do any testing; it’s not logical or realistic, they should only be responsible for making sure that the products they sell have been properly tested. The issue there is that no one is asking for any tests.

The onus is on the producers, and it’s not enough for them to say that they test products, they have to release the results to prove it. Otherwise, they could say whatever they want.

I’m confident that the industry will be responsible enough to react and solve any problems as soon as possible. If producers start releasing results it would make a lot of marketing sense. They could show the public that the product they sell is safe to inhale, and their competitors would have to do the same to remain in the market.

Regulation will eventually require that tests on liquids are mandatory and if advertising is prohibited, as dictated by the regulation of the European Union, I think the only way of marketing your products will be through testing, so the more extensive the testing you do the bigger marketing advantage you have. You won’t be able to sponsor events or advertise on news media, but you’ll get customers by showing that your products are more effective and less harmful than the competition.

What part do vapers, play in this?

Vapers should apply pressure to companies for tests. Vapers should base their choices on test results, not just how the products look or taste, because really it’s more important for them in the long run. It hasn’t worked like that up until now, but eventually I think it will.

I was surprised, to tell you the truth. I was expecting most of the money would come from vapers. But I’m glad I was wrong, because I hadn’t had much of a positive reaction from e-cigarette companies until then.

Usually you find one sponsor for the whole project, research is not normally paid for by crowdfunding campaigns. In fact it’s quite rare and it’s certainly something I haven’t done before. But because it’s been so successful I will do it again.

Do you suspect that some of the companies that funded you might be expecting to seea result in their favor?

Potentially, but that’s not the way we work. We bought the liquids from the market ourselves, in most, if not all, of the cases anonymously, so no one knows which samples we have collected. In the end, it’s of no benefit to those companies to only discuss the positive aspects of vaping.

Is there specific research that you would like to see taking place right now if funding and resources were unlimited?

What we need is long-term follow-up studies, with thousands of participants. But these studies will have to start now and evolve over several years. Smoking has long-term adverse effects; no smoker dies after one year of smoking, that’s why we need to be patient. Also, vapers are generally of a younger age, in their thirties or forties, so the risk of developing disease is small. So to see statistically significant results on an epidemiological level you need to see thousands of them, followed up for years.

40 Comments

olderthandirt

Thanks to Dr. Konstantinos and ECF for providing a voice of reason.

Exclusive ECF Interview: Dr Konstantinos Farsal...

[…] “If you’re expressing your opinion about e-cigarettes in public, you should know what you’re talking about…”Dr Konstantinos Farsalinos is a Greek cardiovascular specialist who in recent years has become increasingly high-profile internationally on account of his groundbreaking clinical research into e-cigarettes and the effects of their use.He spoke to ECF as he embarked on a study into the ingredients of e-liquids that was made possible through crowdfunding by vapers and e-cigarette companies. We talked to him about his work, the future of vaping and how not all the reputed experts are telling the truth. Your day job is in cardiovascular research in a Belgian hospital. What led you from that to focus on e-cigarette research? […]

Adam Lenz

good stuff!

Ray Yeates

Honesty on the internet Finally! Thank you good Dr Farsalinos’ .

Shasta4737

Thank you for researching this, Dr. Farsalino. I would be curious to know what you think about the prescription nicotine inhaler. Has it been researched thoroughly? Also, I’m wondering if you’ve encountered vapors who have a problem with shortness of breath. I smoked heavily for over 30 years without any problems (I’m even a runner) but switched to vaping about five months ago. Right away I noticed that it could make me breathless at times and even cause me to have laryngitis. Still, I like it so much better than smoking and haven’t smoked at all in five months.

Hi Shasta4737. To acknowledge your second question about shortness of breath. I already had COPD (advanced emphysema ) and was still smoking August 2013. My shortness of breath at the time while smoking was limiting my ability to climb the 3 flights of stairs at my residence. I climb then daily. I starting using my electronic device in September of that year and I can tell you honestly that I daily climb those same stairs at a much easier stress than when I was smoking. I have however noticed when starting the day my very first use of the electronic device has on occasion when I use certain flavors and concentrates of glycerine to glycol mixes I do stress a bit more. It quickly becomes not noticable though once I have used the inhalers I need to control my breathing issues otherwise. I hope this observation helps. It is on personal level of course but after asking my lung specialist about this it was his view it is not a great concern in comparison to how smoking would be affecting me at this point. He actually is amazed I’m still doing as good as I am at this point with my COPD. While he did not endorse the device he does not oppose my use of it as long as I stopped smoking.

CrazyVMT

You may have a somewhat rare (but not at all unheard of) sensitivity to “PG” (propylene glycol). Try getting e-liquid that is mostly or all “VG” (vegetable glycerin). This does tend to reduce the “throat hit” feeling, but also tends to increase the vapor production. There are specialty stores that specialise specifically in all-VG and/or “organic” vape liquids. Search the ECF forum, and ask around for more info there.

robbietek

shortness of breathe is common I have read that many people have this after quiting smoking. This is not because of vapping as some would have you think. Both me and my wife have had this problem after shopping smoking with out the use of e-cigs.
I smoked for 37 years and quit in one week with use of e-cigs and have not smoked for a year and I no longer have problems with shortness of breath. I could be the e-liquid but I dont think so.

jim currie

I have just recently got in to supplying E-Liquids in bulk. I have been 30 years in the food ingredients business and I know it is critical to have full traceability on all ingredients. This is demanded for ingredients going for major food companies like Nestle, Britvic , GSK. If you cant trace your ingredients back to origin then you dont get business. The risk is too great. I think many E-Liquids out there have been sold without knowoing who made them or where they come from. Now before anyone talks about China I have dealt with China for 20 years and they can give full traceability . However you have to know them and do a visit and audit.

Knowing this our company offers liquids where we can trace ingredients all the way back. In addition our supplier is accredited to BRC This is British Retail Consortium and demanded in the food business even by major USA groups. It means the company with the BRC quality certificate know what they are doing.

This does not mean we are expensive. Far from it. But we offer good prices with quality products controlled by quality systems. Risk is minimised

Juliet Kelly

I love Dr Farsalinos’s honesty and persistence.. thank you kind sir.

Shasta4737

Thanks for your reply, Ray. That’s great you’re doing so well with vaping! I’ve wondered whether breathlessness and laryngitis from vaping could be just a temporary phenomenon that is basically meaningless. It only happens to me part of the time for a few minutes, but otherwise I’m fine. One thing I’ve been trying to do is to train myself not to inhale into my lungs (at least not often). It’s really satisfying just to vape without doing that. Still, inhaling deeply is a hard habit to break.
Good luck with your vaping!
Shasta

Shasta4737

Jim, is there a way you can provide your website or a place we could find out more about your products? What I’ve been buying doesn’t even list the ingredients. There’s no information at all.
Thanks,
Shasta

Thanks, CrazyVMT. I’ll look into that. I’m also trying to train myself not to inhale into my lungs very much. Really, vaping is pretty satisfying without inhaling so deeply. I do like the throat hit, though. I believe it is possible to get a throat hit and still not inhale deeply. I’m practicing anyway lol.
Thanks!
Shasta

Shasta4737

Thanks, robbietek, I hope that’s what it is with me. The breathlessness really isn’t bad or often, but I’ll be so happy if it’s not the e-liquid.
Thanks!

Jeff Porter

Wow 20mg , that’s like handing a pack and a half a day marlboro smoker some ultra lights and telling them it will help them quit . You have to get rid of the tobacco habit before you get rid of the nicotine habit . The only way to do this besides quitting cold turkey ( if you can ) is to make the body believe nothing has changed . Then you can lower the nicotine rate without all the other chemicals getting in your way . If a person smoked a lot of full flavor cigarettes in a day they probably need at least a 24mg nicotine if not 36 . I hope the UK realizes that , they are only hindering people from quitting and helping the big tobacco companies !

Mark White

Good interview. It’s kind of ironic, though that this interview is posted on the ECF. If you post any viewpoint that in any way resembles the statements of Dr. Farsalino regarding the safety of vaping, such as the need for long term studies and the quantity of unknowns regarding vaping and e-liquids, you are labeled an ANTZ (Anti Smoking Zealot). You are then relentlessly hammered by several very loud voices proclaiming they have it all figured out, there’s sufficient research, and there are absolutely no questions regarding the safety of vaping. I think I’ll refer them to this interview from now on.

Lisabelle

Thank You Dr. Farsalinos

Matt

Quit in nov 13. Used 24mg for 2 weeks ,18 for 3 weeks. Now on 11.
30 yr heavy smoker and I quit using a evod and spinner.
Best thing I ever did.
As for speed of nic into system I know its slow.
Forgot my charger. Went 20 hrs with nothing. Arrived
Home and vaped hard for 15 min.
Never had the rush that reg cigs used to give me.
Still no problem with wanting to go back to “stinkers”.
Thanks to my bro Todd of hitech vapors for talking me into this.
Matt

JenniferG

I’ve been vaping at 5v for nearly 6 years. When I first started I had the shortness of breath and discovered the e-liquid I was using had more VG than I could tolerate. So now when ordering e-liquid I make sure to have only 20% vg & 80 pg%. This might be helpful to you.

Shasta4737

Thanks, Jennifer, I will try that. I’ve been buying e-liquid locally from a tobacco store, but there’s not much choice and the ingredients aren’t even listed. I need to start ordering from a good company.

RoC1909

Awesome interview! I particularly like the questions that were posed to the Doctor. It’s quite insightful to read about what is happening with e-cigarette research.

Threthny

As always. Thanks Dr F. I helped with your crowd-funding and if asked will help again.

occams_chainsaw

7.5 months without a smoke….I usee-cigs and now exercise 45 mins a day….e-cigs have changed my life after 20 years of fighting tobacco. Thanks Dr. Farsalinos for being a stand up guy. The gov’t want us on smokes so they can get some tax money….they don’t care about our lives…just our bank accounts.

John Ferguson

“I wouldn’t suggest non-smokers take up vaping.”
Is this because vaping at any level from 24mg to 0mg is unsafe also? Sucks if vaping really is ONLY for smokers to quit? All these flavors and gadgets are really made for people to eventually, not use?
Suppose vaping really catches on? People quit smoking, start vaping. Eventually, down to zero mg and then stop vaping? I’m not sure I could do the math on how long it would take for both industries to be gone. Admittedly, I did not read the entire piece. I do not know if he covered the dangers of vaping, even at zero nic.

cabbo

From what I’ve seen, ‘mouth-to-lung’ inhales have a heavier throat hit than ‘direct lung’ inhales. Based on products reviews, vlogs, and comments.
Also, if your juice isn’t listing ingredients then you should probably go elsewhere for it. There’s plenty of places online, and most places’ juice will have reviews on youtube. Taste is subjective, but you can avoid anything weird by checking these out.
Depending on where you live, there might even be a brick and mortar shop, and they’ll generally let you try out their juice and let you know what changes different ingredients make.

Shasta4737

I’m not vaping to quit nicotine altogether. I really like vaping and nicotine and hope it won’t hurt my health. I’d like to vape forever!

Stephanie Allen

Thank you good Doctor & team for all that you are doing, giving freely of yourselves & your time to educate our World! I look forward to hearing more and am available if you need US volunteers.

acehack1

We have a vape shop, in Fresno, Ca. I installed a dehumidifier to help keep the clouds of vapor down. It’s only a 30 pint but I empty it once or twice a day. I hope the Dr. reads this because I would think this water would be a great test as it contains the vapor expelled from a hundred or so vapers. At least a good test for secondhand vapor. It is very clear water and smells good. Sublime Vape, instagram, facebook

Dave Chase

While they are now starting to get seriously involved in the research end here’s some actual medical and other documentation you may want to pass along to the good Doc there! The first is the CASAA funded study resulting in the 22 page Drexel Medical University Tech Report seen at http://publichealth.drexel.edu/~/media/files/publichealth/ms08.pdf

[…] If you still haven’t read this brilliant interview with Dr. Konstantinos Farsalinos, make sure you do http://www.e-cigarette-forum.com/infozone/news/exclusive-ecf-interview-dr-konstantinos-farsalinos.ht… […]

Great interview, thanks for this! It pains me to no end that juice manufacturers who “test” their juice, and then refuse to publish the results! Hopefully they will read this and learn from their mistakes.